E. Malik

Fluorescence diagnosis of endometriosis using 5-aminolevulinic acid

AbstractBackground: The diagnosis of nonpigmented endometrial lesions by simple laparoscopic visualization is difficult and often inaccurate. We therefore sought to establish a new and more accurate method to visualize these nonpigmented peritoneal changes caused by endometriosis. Methods: A total of 37 patients received 30 mg 5-aminolevulinic acid/kg body weight 10 to 14 hs prior to surgery. Laparoscopy was then performed using a D-light system (Storz, Tuttlingen, Germany). The findings were evaluated first in the white-light mode; the D-light system was then activated, and all areas of fluorescence were documented. Multiple specimens were obtained by biopsy. Results: The sensitivity of the fluorescence diagnosis in detecting endometriosis in nonpigmented areas and normal-looking peritoneum is 100%, with a specificity of 75%. Diagnosis by simple visualization under white illumination has a sensitivity of only 69% and a specificity of 70%. Occult areas of endometriosis were discovered using fluorescence diagnosis. Conclusions: Our findings suggest that fluorescence diagnosis using 5-aminolevulinic acid is feasible and can improve the diagnosis of endometriosis in nonpigmented and occult endometrial lesions. Fluorescence diagnosis is a promising new tool in the diagnosis of endometriosis.

Prospective evaluation of the systemic immune response following abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy

BackgroundAlterations in serum levels of cytokine interleukin-6 (IL-6) and acute-phase protein C-reactive protein (CRP) correlate directly with extent of tissue damage and inflammatory reaction. We therefore prospectively compared the postoperative levels of IL-6 and CRP following abdominal (AH), vaginal (VH), and laparoscopically assisted vaginal hysterectomy (LAVH).MethodsA total of 29 patients were included in the study (10 VH, 10 LAVH, 9 AH). Nine blood samples were taken from each patient at various time points before, during, and after surgery. CRP and IL-6 were measured under standardized conditions using ELISA and turbidometry.ResultsPreoperative levels of IL-6 and CRP were low in all three patient groups. There was a significant increase in the IL-6 level in patients undergoing AH at the time of peritoneal closure that reached a maximum 2 h postoperatively and remained significantly elevated for 12 h postoperatively when compared to the IL-6 levels of patients undergoing VH or LAVH (p<0.05). The levels of the IL-6 time courses differed significantly among the three operative procedures (p=0.013). In contrast, the levels of the CRP time courses did not differ significantly (p=0.066); however, CRP expression was elevated 36 h postoperatively in patients undergoing AH, as compared with those undergoing VH.ConclusionElevated IL-6 levels subsequent to AH may reflect significantly greater tissue damage in these patients than in patients who undergo VH or LAVH. LAVH should therefore be considered in cases that cannot be managed by the vaginal route alone.

Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis: a retrospective analysis.

BackgroundAdhesions are believed to be one of the principal causes of chronic pelvic pain. Although there may be some discrepancy between the degree of adhesions and the severity of the symptoms, surgical adhesiolysis is still considered to be useful for the relief of pain.MethodsA total of 187 patients who underwent laparoscopic adhesiolysis at the Medical University of Ulm, Germany, within a 2-year period were asked to rank their discomfort on a visual pain scale before surgery and up to 1 1/2 years postoperatively.ResultsIn this retrospective study, we found that nearly one-third of patients suffered from functional irritations that were either ameliorated or completely relieved by laparoscopic adhesiolysis. When other causes of chronic pain (such as endometriosis) are excluded, the results show that most patients benefited from laparoscopic adhesiolysis.ConclusionsIt appears that laparoscopic adhesiolysis is an effective therapeutic measure to relieve chronic pelvic pain. Therefore, adhesiolysis should be performed in all patients with chronic or intermittent pain, and a complete lysis of adhesions should be planned. However, since pelvic pain may have organic or functional causes other than adhesions, complete adhesiolysis in patients with persistent pelvic pain may be of only limited importance.

Laparoscopic management of tubo-ovarian abscesses: retrospective analysis of 60 cases.

BackgroundThe laparoscopic management of tubo-ovarian abscesses (TOA) was evaluated. The study sought to answer the following question: Does operative laparoscopy with only incision of the abscess cavity and lavage (organpreserving treatment) improve intraoperative and postoperative safety and long-term prospects of fertility as compared with laparoscopic salpingectomy or salpingo-oophorectomy (ablative treatment)?MethodsA retrospective chart review of 60 patients with TOA undergoing laparoscopic treatment in combination with broad-spectrum antibiotics from 1994 to 1998 was performed. Patients not wishing to have children underwent salpingectomy or salpingo-oophorectomy, whereas patients wishing to remain fertile were treated by means of an organpreserving procedure. To investigate the operative and reproductive outcome, patients were interviewed by telephone.ResultsOf 60 women with TOA, 25 were treated laparoscopically, preserving the internal genital organs, and 35 underwent ablative treatment. Apart from one postoperative readmission because of lower pelvic pain in the organpreserving group, there were no operative complications or serious systemic sequelae. In contrast, there was a significantly higher incidence of intraoperative and postoperative complications when ablative treatment was performed: one intestinal perforation requiring subsequent laparotomy, four serosal lesions, two lesions of the greater omentum, two lacerated collaterals of the internal iliac artery, one postoperative fever higher than 38°C for 2 days, two bowel obstructions, one thrombosis of the upper leg, and one thrombosis of the lower leg. There were no significant differences between the two patient groups in body mass index, duration of pelvic pain, laboratory findings at admission, ultrasonic assessment of abscess size, and the extent of the abscess at laparoscopy.ConclusionsWhen laparoscopic treatment of TOA is performed, organ-preserving treatment should be chosen irrespective of the patient’s age or desire to have children because of the risk of complications.

Vascular endothelial growth factor mRNA in eutopic and ectopic endometrium

OBJECTIVE To evaluate changes in expression levels of vascular endothelial growth factor (VEGF) mRNA in human endometrial explants in a chicken chorioallantoic membrane model of endometriosis. DESIGN Experimental prospective study. SETTING University hospital. PATIENT(S) Endometrial biopsy samples were obtained from healthy, ovulating women undergoing elective surgery. INTERVENTION(S) Endometrial fragments were placed on the chicken chorioallantoic membrane and removed for analysis after 0, 24, 48, and 72 hours. MAIN OUTCOME MEASURE(S) Expression of different VEGF mRNA splice variants was tested. Expression of VEGF(165) mRNA was assessed by using competitive polymerase chain reaction and normalized to expression of the housekeeping gene human glyceraldehyde 3-phosphate dehydrogenase (GAPDH) mRNA. RESULT(S) After 0, 24, 48, and 72 hours of incubation, all grafts expressed VEGF(121), VEGF(145), VEGF(165), and VEGF(189) mRNA. Expression of VEGF(165) mRNA increased up to 10-fold at 24 to 72 hours compared with precultivation values. CONCLUSION(S) Levels of VEGF(165) mRNA in endometrial grafts increase after implantation on chicken chorioallantoic membrane. Hypoxic induction of VEGF mRNA expression in endometrial cell cultures has been reported previously. Induction of VEGF expression might indicate relative hypoxia of the specimen due to insufficient vascularization. Expression of VEGF may assist in vascularization of endometrial explants after retrograde menstruation.

Endometrial expression of estrogen receptor β and its splice variants in patients with and without endometriosis.

BackgroundThe role of estrogen receptor beta (ERβ) in pathogenesis of endometriosis remains to be elucidated. In this study, we have examined the expression of the four main ERβ transcript isoforms in human endometrial tissue in women with or without endometriosis.MethodsTotal RNA was isolated from native endometrial tissue and transcript levels of ERα, β1, β2, β4, β5 were analyzed by means of RT-PCR. We compared the results with regard to menstrual cycle phase as well as to presence or absence of endometriosis. We prospectively harvested the endometrium of ten women without endometriosis (five for each cycle phase) and eight patients with endometriosis (five in the proliferative phase, three in the secretory phase).ResultsERα, β1, β2, and β5 transcripts were detected in both cycle phases. During the proliferative phase, healthy women had a significantly higher ERα/ERβ1-ratio than patients with endometriosis. Irrespective of the cycle phase, ERα-mRNA level was significantly higher than transcript levels of ERβ isoforms.ConclusionsERα, β1, β2, and β5 are expressed in human endometrium. The individual receptors differed in terms of expression strength but there was no relevant change during the cycle. The decreased ERα/ERβ1-ratio in proliferative endometrium of endometriosis patients suggest that ERβ1 might be involved in the pathogenesis of endometriosis. Further studies should be undertaken to substantiate the role of ERβ in endometrial pathology.

Differential induction of matrix metalloproteinase 1 and 2 in ectopic endometrium

According to the transplantation theory, endometriosis develops from endometrial fragments that are retrogradely menstruated into the peritoneal cavity. In order to develop into endometriotic lesions, they have to connect to the vascular system by angiogenesis, probably involving matrix metalloproteinases (MMP) as key enzymes in extracellular matrix remodelling. A model of endometriosis using the chorioallantoic membrane (CAM) of chick embryos was established. Eutopic endometrium from healthy women was transferred to the CAM and cultivated ectopically for up to 3 days. Before transplantation and after 24, 48 and 72 h of culture on the CAM, total RNA was extracted and reverse transcribed. Human MMP-1 (interstitial collagenase) and MMP-2 (gelatinase A) mRNA expression was assessed by competitive PCR. Results were normalized to the content of human glyceraldehyde 3-phosphate dehydrogenase (GAPDH) mRNA. In eutopic endometrium, 0.29 amol MMP-1 mRNA and 0.42 fmol MMP-2 mRNA per fmol GAPDH mRNA were found. Relative MMP-1 mRNA concentrations increased strongly after culture on the CAM, while MMP-2 mRNA levels were nearly unaltered. This differential regulation suggests different roles of these enzymes in the angiogenesis of ectopic endometrial fragments and during the development of endometriosis.

Matrix metalloproteinase messenger RNA expression in human endometriosis grafts cultured on a chicken chorioallantoic membrane

OBJECTIVE To investigate the role of matrix metalloproteinase 1 and 2 (MMP-1/MMP-2) in human endometrial explants in a chicken chorioallantoic membrane model (CAM) of endometriosis. DESIGN Experimental prospective study. SETTING University hospital. PATIENT(S) Endometrium samples obtained from ovulating women, both healthy and patients with endometriosis, who were undergoing curettage and diagnostic laparoscopy for benign gynecologic conditions. INTERVENTION(S) Endometrial grafts were transplanted to the CAM and cultured for 0, 24, 48, 72, and 96 hours. MAIN OUTCOME MEASURE(S) Expression of MMP-1 and MMP-2 messenger RNA (mRNA) was quantified by competitive reverse-transcriptase polymerase chain reaction (RT-PCR) and normalized to expression of the housekeeping gene human glyceraldehyde 3-phosphate dehydrogenase (GAPDH) mRNA. RESULT(S) All grafts expressed MMP-1 and MMP-2 mRNA. The endometrium of healthy women and patients with endometriosis showed a statistically significant increase of MMP-1 mRNA expression 24, 48, 72, and 96 hours after transfer to the CAM. An increase of MMP-2 mRNA expression was only detected after 96 hours of CAM culture in patients with and without endometriosis. No statistically significant difference regarding the MMP-1 and MMP-2 mRNA expression could be shown in healthy women or endometriosis patients. CONCLUSION(S) Our data suggest that MMP-1 and MMP-2 are major factors involved in the invasion of endometrium into the peritoneum and in vascularization of endometriosis. Whether MMPs are suitable targets for treatment of endometriosis has to be examined in further studies.

Reproductive outcome of 32 patients with primary or secondary infertility and uterine pathology

Abstract We did a retrospective study on 102 patients who had a laparoscopy and a hysteroscopy during investigations for primary or secondary infertility. 32 of the 102 patients had uterine pathology. Seven of them had septate uteri, eight had uterine synechiae, another six had uterine fibroids, four had a bicornuated uterus, while the remaining had either a combination of all or other uterine anomalies. After surgical treatment of these conditions ten women conceived and five pregnancies including one twin pregnancy resulted in term deliveries.

Endometriose und Aktivität

ZusammenfassungHinter der Vielzahl der Erscheinungsbilder der Endometriose verbergen sich unterschiedlich “aktive” Areale der Erkrankung. Die nicht pigmentierten Läsionen der Endometriose gehen mit einer erhöhten Expression von unterschiedlichen Wachstumsfaktoren und Zytokinen einher. Dadurch unterscheiden sie sich von pigmentierten Läsionen der Endometriose. Setzt man die erhöhte Expression bestimmter Parameter mit “Aktivität” gleich, bedeutet dies, dass die nicht pigmentierten Läsionen aktive Formen der Erkrankung darstellen.Die bisherigen klinischen Resultate berücksichtigen die Aktivität der Erkrankung nicht oder nur marginal. Eine exakte Dokumentation der Aktivität während der diagnostischen/operativen Laparoskopie stellt die Grundvoraussetzung für eine adäquate Therapie dar. Darüber hinaus liefert die Kenntnis über biochemische Eigenschaften der Endometrioseläsionen wichtige Rückschlüsse auf die Pathogenese der Erkrankung und eröffnet so neue Therapieoptionen.AbstractThe numerous morphologic aspects of different endometriotic lesions can be related to different stages of activity of the endometriotic disease. Non-pigmented endometriotic lesions are demonstrating higher levels of growth factors and cytokines than pigmented lesions. It seems that high levels of growth factors (VEGF, angiopoietins, MMP) are related with high biologic activity, therefore the pigmented lesions represent the active manifestation of the disease.Until now most clinical studies have not taken into account the activity of the disease. An exact documentation of the activity during laparoscopy represents a prerequisite for an adequate therapy. Furthermore, the improvement of our knowledge will lead to a better understanding of the pathogenesis of the endometriotic disease and to new options in the treatment of endometriosis.